Care Study Osteomyelitis

8/6/2019 Care Study Osteomyelitis

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LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING1st Semester 2009 2010

In Partial Fulfillment of NCM 50124Related Learning Experience

Care StudyCare StudySubmitted to:

Mrs. Joei OliverosClinical Instructor

Submitted by:Tiu, John T.Aquino, JoeySazon, GianAzuela, Ariel

Student


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TABLE OF CONTENTS

I. INTRODUCTION

A. Overview

B. Objective and Purpose of the Study

C. Scope and Limitation

II. HEALTH HISTORY

A. Profile of patient

B. Family and personal health history

C. History of present illness

D. Chief complaint

III. DEVELOPMENTAL DATA

IV. MEDICAL MANAGEMENT

A. Medical orders and rationale

B. Drug study

V. PATHOPHYSIOLOGY WITH ANATOMY & PHYSIOLOGY

VI. NURSING ASSESSMENT (SYSTEM REVIEW & NSG.

ASSESSMENT II )

VII. NURSING MANAGEMENT

A. Ideal Nursing Management (NCP)

B. Actual Nursing Management (SOAPIE)

VIII. REFERRALS & FOLLOW-UP

IX. EVALUATION & IMPLICATIONS

X. BIBLIOGRAPHY


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I. INTRODUCTION

Osteomyelitis is an infection of bone or bone marrow with a propensity for

progression, usually caused by pyogenic bacteria or mycobacteria. It can be

usefully sub classified on the basis of the causative organism, the route,

duration and anatomic location of the infection. By definition osteomyelitis is

inflammation of the bone and marrow, but, since it is always caused by an

infection, it implies an infection.

Osteomyelitis is inflammation and destruction of bone caused by bacteria,

mycobacteria, or fungi. Common symptoms are localized bone pain and

tenderness with constitutional symptoms (in acute osteomyelitis) or without

constitutional symptoms (in chronic osteomyelitis). Diagnosis is by imaging

studies and cultures. Treatment is with antibiotics and sometimes surgery.

The bone become becomes infected in three ways:

Extension of soft tissue infection

- infected pressure or vascular ulcer

- incisional infection

Direct bone contamination from bone surgery, open fracture, or

traumatic injury

gunshot wound

Hematogenous (blood borne) spread from the other sites of infection

Infected tonsils, boils, infected teeth, upper respiratory infection

Osteomyelitis resulting from hematogenous spread typically occurs in a

bone in an area of trauma or lowered resistance, possibly from subclinical

(nonapparent) trauma.
http://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Pyogenichttp://en.wikipedia.org/wiki/Bacteriahttp://en.wikipedia.org/wiki/Mycobacteriahttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Pyogenichttp://en.wikipedia.org/wiki/Bacteriahttp://en.wikipedia.org/wiki/Mycobacteria


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A. OBJECTIVE

This study aims to aid students on problems related to the patients

condition and understand what the disease process is all about. It is also

conducted to promote health care delivery and identify the clients

immediate needs.

B. SCOPE & LIMITATION OF THE STUDY

This study was conducted within a 16-hours duty at Northern

Mindanao Medical Center which focuses on the information about the

patient and her condition as well as the immediate interventions required.

C. SIGNIFICANCE OF THE STUDY

The study focuses on the disease condition of the patient and itsunderlying causes. We aimed to have a much deeper understanding

about the disease process for us to know proper interventions and

conduct health teachings to the patient. The study also aims to promote

health wellness not only for the benefit of the patient but also for the

significant others.


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II.HEALTH HISTORYA. Profile of patient

Name: Villegas, Mark ZandroAge: 18 years oldSex: MaleBirth Place: Makati CityBirthday: August 21 1991Civil Status: SingleNationality: FilipinoInformant: Himself Religion: Born AgainAddress: Purok 3 La Verdad Talisayan Mis. Or Weight: 40 kgHeight: 54Temperature: 38 CPulse rate: 84 bpmRespiratory rate: 24 cpmBlood pressure: 120/80 mmHg

Clinical Profile

Date of Admission: August 11, 2009Time of Admission: 3: 00 PMAttending Physician: Dr. Roem F. Castillano MD.Chief of complaint : Fever Admitting Diagnosis : Chronic OsteomyelitisDiet: DATAllergy: none


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B. HEALTH HISTORY

Villegas, Mark Zandro 18 years old, was born on August 21, 1991 at

Makati City in a Normal Spontaneous Vaginal Delivery (NSVD). The patient

had an operation last December 2008 due to fracture at right femur. The

patient also experienced having headaches, cough and colds, as well as

fever for a couple of times in a year. Her mother usually gave him OTC

medication for the relief of the aforementioned illnesses.

C. HISTORY OF PRESENT ILLNESS

The patient was admitted at Northern Mindanao Medical Center on

August 11, 2009 at 3 PM due to fever.

Two days prior to admission, the patient had an on and off fever. Fever

was relieved by Paracetamol 500mg, 1 tablet every four hours. No other

medications were given and no consult was made. The patients conditionwent on and off.

Morning prior to admission, condition persisted patient has sudden

undocumented fever and the day after fever.

Assessment was done during admission vital signs were checked for

baseline data: temperature, 38 oC; pulse rate, 84bpm; respiratory rate,

24cpm; and blood pressure, 120/80 mmHg and weight, 40 kg.

D.The patient was diagnosed Chronic Osteomyelitis Right Femur


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III.DEVELOPMENTAL HISTORY

A. Erik Eriksons Stages of Psychosocial Development Theory

Erikson describes eight developmental stages through which a

healthily developing human should pass from infancy to late adulthood . In

each stage the person confronts, and hopefully masters, new challenges.

Each stage builds on the successful completion of earlier stages. The

challenges of stages not successfully completed may be expected to

reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful

resolution will result in a favorable outcome and by an important event that

this conflict resolves itself around

The subject is a 17 year old, high school student which is under the

5 th stage of Ericksons psychosocial stage. This begins with puberty and

ending around 18 or 20 years old. The task during adolescence is to

achieve ego identity and avoid role confusion. Ego identity means knowingwho you are and how you fit in to the rest of society. It requires that you

take all you've learned about life and yourself and mold it into a unified

self-image, one that your community finds meaningful.

B. Sigmund Freuds Psychosexual Development Theory

Freud advanced a theory of personality development focusing on

the effects of the sexual pleasure drive on a person's emerging

personality. According to his theory, parts of the personality develop as we

move through a series of psychosexual stages. Each stage is

characterized by different demands for sexual gratification and different

ways of achieving that gratification.
http://en.wikipedia.org/wiki/Erik_Eriksonhttp://en.wikipedia.org/wiki/Developmental_stagehttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Adulthoodhttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erik_Eriksonhttp://en.wikipedia.org/wiki/Developmental_stagehttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Adulthoodhttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development


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The drives that have been responsible for gratification in the

previous stages appear relatively inactive. The patients repressed drives

were redirected into other activities, such as the formation of friendships,

or hobbies.

Robert J. Havighursts Developmental Task Theory

The tasks involved which need to be accomplished by the patient

are:

Achieving new and more mature relations with age-mates of both

sexes

Achieving a masculine or feminine social role

Accepting one's physique and using the body effectively

Achieving emotional independence of parents and other adults

Preparing for marriage and family life Preparing for an economic

career

Acquiring a set of values and an ethical system as a guide to behavior;

developing an ideology

Desiring and achieving socially responsible behavior

C. Jean Piagets Theory of Development

According to Piaget, development is driven by the process of

equilibration. Equilibration encompasses assimilation and accommodation

The patient is classified under the last stage in Piaget's theory

which is the formal operations stage. This stage exists between the ages

of about twelve to adulthood. Children in this stage are capable of thinkinglogically and abstractly and reason theoretically. Piaget considered this

stage the ultimate stage of development.


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IV. Medical Management

a. Medical Orders and Rationale


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DIAGNOSTIC EXAMINATIONS

DOCTORS ORDER RATIONALE09-14-09

> TPR q 4h

> DAT

> Paracetamol 500mg PO for Fever >Tramadol 500 mg IVTT PRNfor pain

> CBC

>Urinalysis

> D5LR @ 20gtts/min

09-15-09

> TPR q 4h

> DAT

>Nafcillin sodium 1 gm IVTTevery 8 hours

> IVF follow up D5LR @ 20gtts/min

> During this period of time, potentially fatalcomplications may develop

> Re-establish normal eating pattern

> To reduce fever by direct action on theHypothalamus>to relieve pain

>CBC-, although a high WBC counts maypresent in viral infection.

> To know the presence of bacteria in the urine

> Fluids are required to replace losses, toprevent patient dehydration. For hydrationpurposes

> To monitor patients V/S

> Re-establish normal eating pattern

Acute to chronic osteomyelitis caused bysusceptible organism

> Fluids are required to replace losses, toprevent patient dehydration. For hydrationpurposes.


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N/O

B.DRUG STUDY

Name of drug,

dosage, route

Indication Nursing Precaution

Paracetam

ol 500mg PO

for temperature >

38 oC

Tramadol

50 mg IVTT

PRN for Pain

Nafcillin

sodium 1 gm

IVTT every 8

hours

Antipyretic lowers downfever with its direct action onthe hypothalamus

Moderate to moderatelysevere pain

Acute or chronic

osteomyelitis caused bysusceptible organism

Do not give to patient morethan 5 times in 24 hours notunless prescribed by the

physician.

Patient increased intracranialpressure or head trauma.Dosage adjustment may berequired for pt. with cirrhosisor renal impairment.


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VI.NURSING SYSTEM REVIEW CHART

EENT:Impaired vision blindpain reddened drainagegums hard of hearing deaf burning edema lesion [x] teeth

Asses eyes, ears, noseThroat for abnormality [ ] no problemRESPIRATION

asymmetric tachypneaapnea rales [ ] cough barrel chestbradypnea shallow rhonchisputum diminished dyspneaorthopnea labored wheezingpain cyanotic

Asses resp. rate, rhythm, depth, patternbreath sounds, comfort [x] no problemCARDIO VASCULAR

arrhythmia tachycardia numbnessdiminished pulses edema fatigueirregular bradycardia murmur tingling absent pulses pain

Assess heart sounds, rate, rhythm, pulse, blo odpressure, etc., fluid retention, comfort[x] no problemGASTRO INTESTINAL TRACT

obese distention massdysphagia rigidity pain

Asses abdomen, bowel habits, swallowing,bowel sounds, comfort [x] no problemGENITO-URINARY and GYNE

pain urine color vaginal bleedinghematuria discharge nocturia

Assess urine freq., control, color, odor, comfort/Gyn-bleeding, discharge [x] no problemNEURO

paralysis stuporous unsteady seizureslethargic comatose [ ] vertigo tremorsconfused vision grip

Assess motor function, sensation, LOC, strength,grip, galt, coordination, orientation, speech.

[x] no problemMUSCULOSKELETAL and SKIN

appliance stiffness [x] itching [] petechiaehot drainage prosthesis swellinglesion poor turgor cool [x] deformitywound rash skin color flushedatrophy [x] pain ecchymosisdiaphoretic moist

Asses mobility, motion, galt, alignment, joint function/skin color, texture, turgor, integrity no problem

Place an (X) in the area of abnormality. Comment at thespace provided. Indicate the location of the problem inthe figure if appropriate, using (x)

Tooth Decay

P

Dry and flushed skin

Febrile T: 38 CPain4/10 , itchyness

Present of wound

Pus, ulcer on the right

femur

Dirty Toenails

Headache

Skin is warm to

touch

Name: Villegas, Mark Zandro Date: August 14, 2009Vital Signs:Pulse: 84 bpm BP: _ 120/80 mmHg Temp: _ 38C Height :54 Weight :40kg


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SUBJECTIVE OBJECTIVE

COMMUNICATION:

[ ] hearing difficulty

[ ] visual changes

[x]denied

Comments: okay ramanakomg paglantaw ug angakong pandungog asverbalized by the patient

[ ] glasses [ ] languages

[ ] contact lenses [ ] hearing difficulties

Pupil size:R:3 mm L:3mm [ ] speech difficulties

Reaction: PERRLA (Pupil Equally Round Reactiveto Light and Accommodation)

OXYGENATION:

[ ] dyspnea

[ ] smoking history

Non-smoker

[ ] cough

[ ] sputum

[x]denied

Comments: Dili man kogapanigarilyo as

verbalized by the patient

Resp. [x] regular [ ] irregular

Describe: There was no difficulty of breathing or shortness of breath that was noted

R: full and symmetrical to the left lung

L: full and symmetrical to the right lung

CIRCULATION:

[ ] chest pain

[x] leg pain

[ ] numbness of

extremities

[ ]denied

Comments: hhm. Usahaymosakit akong tiil peroma wala wala rman pudang kasakit asverbalized by the patient

Heart Rhythm [x ] regular [ ] irregular

Ankle Edema: No ankle edema is present on both

extremitiesPulse Car Rad. DP Fem*

R + 84 bpm + +

L + 84 bpm + +

Comments: All pulses were palpable on both upper and lower extremity

NUTRITION:

Diet: DAT

Character

[ ] recent change inweight

[ ] swallowing

Difficulty

[x]denied

Comments: okay ramanakong pagkaon dili manko galisod pud as

verbalized by he patient

[ ]dentures [x]none

Full Partial with patient

Upper [ ] [ ] [ ]

Lower [ ] [ ] [ ]


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ELIMINATION:

Usual bowel pattern

Once a day

[ ] constipation

Remedy

[ ] diarrhea

character

[ ] urinary frequency

Twice a day

[ ] urgency

[ ] dysuria[ ] hematuria

[ ] incontinence

[ ] polyuria

[ ] foley in place

[x]denied

Comments: bowelsounds (Normoactive).

Not Applicable.

Bowel sounds Audiblenormoactive bowelsounds

Abdominal Distention

Present [ ] yes [x] no

Urine* (color,consistency, odor)

Urine color is yellowish,moderate amount andaromatic in odor.

*if they are in place

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [x] denied

(amount & frequency)

N|A

[ ] SBE: N/A Last Pap Smear: N/A LMP: N/A

Briefly describe the patients ability to followtreatments (diet, meds, etc.) for chronic healthproblems (if present).

Prescribed by physician and proper nutrition in dietwas enforced

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY:

[x] dry

[ ] other

[ ] denied

Comments: ga dry akongsamad sa tiil as verbalized bythe patient

[x] dry [ ] cold [ ] pale

[ ] flushed [x ] warm

[ ] moist [ ] cyanotic

*rashes, ulcers, decubitus (describe size,location, drainage: (-) rashes; (+) ulcers ; (-)decubitus (1 peso coin size, right femur mod.amount)

ACTIVITY/ SAFETY:

[ ] convulsion

[ ] dizziness

[ ] limited motion of

Joints

Limitation in

Ability to

[ ] ambulate

[ ] bathe self

[ ] other

Comments: Maka lihok lihokman ko pero usahay mosakitakong tiil as verbalized by thepatient

[ ] LOC and orientation: patients knows where she is and knows what day today.

Gait: [ ] walker [ ] cane [ ] other

[ x] steady [ ] unsteady:

[ ] sensory and motor losses in face or Extremities: There was no motor and sensorylosses in face and extremities noted from thepatient

[ ] ROM limitations: The patient is able to flex,extend, rotate the head


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[ x ] denied

COMFORT/SLEEP/

AWAKE:

[x] pain

(location) femur right

Frequency

Remedies

[ ] nocturia

[ ] sleep difficulties

[ ] denied

Comments: Sakit sakit usahayakong tiil, pero ma tolerateraman pud as verbalized by

the patient

[x] facial grimaces

[x] guarding

[ ] other signs of pain :[ ] side rail release form signed (60 + years)

N/A

COPING:

Occupation: None

Members of household: 5 membersMost supportive person: her father

Observed non-verbal behavior: None

Phone number that can be reached anytime:Not given


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VII NURSING MANAGEMENT

A.IDEAL NURSING MANAGEMENT

A. Hyperthermia related to present of pathogens in the body asevidenced by increase in body temperature higher than normal range.

Desired outcomes/evaluation criteriapatient will:Demonstrate temperature within normal range, be free of chills.

INTERVENTION RATIONALEIndependent

monitor patienttemperature(degree andpattern); note shakingchills/profuse diaphoresis.

Monitor environmentaltemperature; limit/add bedlinens as indicated.

Provide tepid sponge baths;avoid use of alcohol.

Dependent

Administer antipyretics,paracetamol 500mg PO

Provide cooling blanket.

Temperature of 38 degree Csuggests acute infectious diseaseprocess. Fever pattern may aid indiagnosisr; remittent fever (varyingonly a few degrees in either direction) reflects pulmonaryinfections; intermittent curves or fever that returns to normal once in24-hour period suggests septicepisode, septic endocarditis, or tuberculosis (TB). Chills oftenprecede temperature spikes.

Note: Use of antipyretics alters fever patterns and may be restricted untildiagnosis is made or if fever remainshigher that 102F (38.9C). Room temperature/number of

blankets should be altered tomaintain near-normal bodytemperature.

May help reduce fever. Note: use of ice water/alcohol may cause chills,actually elevating temperature. Inaddition, alcohol is very drying toskin.

Used to reduce fever by its centralaction on the hypothalamus;However, fever may be benefial in


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limiting growth of organisms andenhancing autodestruction of infected cells.

Used to reduce fever, usually higher than 104F-105F (39.5C-40C), when

brain damage/seizures can occur.

B. Acute pain related to inflammation and tissue necrosis

DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:

Will b relieved of experiencing pain and shows relief and relax

physical and emotional outlook.

ACTIONS/INTERVENTIONS RATIONALEIndependent

Perform a comprehensiveassessment of pain to includelocation, characteristic,onset/duration, frequencyseverity(0-10 scale)

Instruct use of relationexercise such as focused

breathing, commercial or musics.

Encourage adequate restperiod (ex. TV and radio).

Encourage diversionalactivities.

Dependent

Administer medications asindicated,

To know how intense is thepain and

to asses in relieving the pain.

To provide diversionalactivities.

To prevent fatigue andpromote wellness

To divert the attention of thepatient to diminish pain.

To lessen the pain

.


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C.Knowledge deficient regarding condition, related to unfamiliarity withdisease.

Desire outcomes/evaluation criteria- the significant others will:

Verbalize understanding of disease processes, possiblecomplications.

INTERVENTION RATIONALEINDEPENDENT

Determine the mothers perceptionof disease process.

Review disease process,cause/effect relationship of factorsthat precipitate symptoms, and

identify ways to reducecontributing factors. Encouragequestions.

Review medications, purpose,frequency, dosage, and possibleside effects.

Stress importance of good skincare, e.g., proper handwashingtechniques.

Emphasize need for long-termfollow-up and periodicreevaluation.

Establishes knowledge base andprovides some insight into individuallearning needs.

Precipitating/aggravating factors areindividual; therefore, the mother needs to be aware of what foods,

fluids, and lifestyle factors canprecipitate symptoms. Accurateknowledge base providesopportunity for the mother to makeinformed decisions/choices aboutfuture and control of chronicdisease. Although most others knowabout their own disease process,they may have outdated informationor misconceptions.

Promotes understanding and mayenhance cooperation with regimen.

Reduces spread of bacteria and riskof skin irritation/breakdown,infection.

Provides opportunity for evaluationof effectiveness of regimen.

32e2323


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B. Actual Nursing Management (SOAPIE)

Sgilantan ko, init akong panit as verbalized by the patient

OT- 38 degree C

Skin is warm to touch

AHyperthermia related to present of pathogens in the body.

PAt the end of 2 hours the patient will be able to lower down body the

body temperature from 38 degree C to normal range

I

1. Provided tepid sponge bath

2.Encouraged the patient to drink water at least 10-12 glasses a day

3. Provided adequate rest period

4. Administered paracetamol 500 mg PO as prescribed by the

physician

E At the end of 2 hours the patient was able to lower down thetemperature from 38 degree C to normal range


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SSakit akong tiil kong i-lihok-lihok as verbalized by the patient

Oguarding

facial grimace

pain-pain scale of 4/10

AAcute pain related to inflammation and tissue necrosis

PAt the end of 2 hours the patient will be able to ease the pain and the

pain scale will lower down from 4/10 to 1/10

I

1. Performed a comprehensive assessment of pain

2.Encouraged verbalization of feelings about the pain

3. Provided comfort measure (change of position)

4. Encouraged use of relaxation exercises such as deep breathing

5 Administered pain reliever as prescribed by the physician (50mg

Tramadol IVTT for pain)

E At the end of 2 hours the patient was able to ease the pain and the

pain scale was lower down from 4/10-to-1/10


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IX. EVALUATION AND IMPLICATIONS

At the end of my hospital duty, we as a student nurse were able to render

care to our patient to help him resolve his problem regarding health. Through

observing the patients status, we were able to identify some problems during our

assessment.

Patient was willing to pursue his medical therapy just to promote health

and wellness for the betterment of his condition. During the treatment, the patient

was able to develop or enhance health awareness on his disease and with this

knowledge instilled to his mind, he was then aware on how the disease was

transmitted and what are the proper ways or interventions done just to minimizeor prevent this disease from getting worst.

We have also made the patient realize the importance of completing the

course of therapy by taking the medicines prescribed or ordered to him by his

physician. In addition, eating healthy or nutritious foods that were prescribed to

him by the health providers was further been explained to him especially the

benefits he will gain in eating these nutritious foods.

In general, the patient was very cooperative to what health measuresadministered to him by the health providers.

Moreover, these several interventions given to the patient made his body

functions different than as before .


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X. BIBLIOGRAPHY

Lippincott Williams and Wilkins, Nursing 2006 Drug Handbook, 26 th

Edition,

Barbara Kozier et al, Fundamentals of Nursing, 7 th Edition,

Lippincott Williams and Wilkins, Nursing 2004 Drug Handbook, 24rd

Edition,

Mosbys Pocket Dictionary of Medicine, Nursing Allied Health, 4 th

Edition, Published in Elsevier Science (Singapore) PTE LTD

Microsoft Encarta Premium Suite 2005. 1993-2004 Microsoft

Corporation. All rights reserved.

Mosbys Comprehensive Review of Nursing, 13 th Edition by:

Saxton,Nugent,Pelikan

http://www.cnn.com/HEALTH/library/DS/00583.html

Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott

Williams & Wilkins, Philadelphia, USA Mosbys MEDICAL ENCYCLOPEDIA, the definitive health reference

http://www.wrongdiagnosis.com/p/leptospirosis/symptoms.htm

http://en.wikipedia.org/wiki/diabetic

http://www.emedicine.com/med/topic1776.htm

http://www.gicare.com/pated/ecdgs09.htm
http://www.wrongdiagnosis.com/p/leptospirosis/symptoms.htmhttp://www.emedicine.com/med/topic1776.htmhttp://www.gicare.com/pated/ecdgs09.htmhttp://www.wrongdiagnosis.com/p/leptospirosis/symptoms.htmhttp://www.emedicine.com/med/topic1776.htmhttp://www.gicare.com/pated/ecdgs09.htm


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Documents

Care Study Osteomyelitis